Welcome to Chipur! If you’re struggling with a mood or anxiety disorder, you’ve come to a good place. Dig-in, okay? Thank you for stopping-by. Bill

Antidepressants: The Need-to-Know Series (Part 3: The SSRIs, SNRIs, NDRI)

Your neighbor can’t stop talking about the wonders of Lexapro. She suggests you talk to your doctor about an SSRI for your depression and anxiety. You reply, “What’s an SSRI?”

In Part 1 of our our series we reviewed some history, the tricyclic antidepressants (TCAs), and the tetracyclic antidepressants (TeCAs). And we covered the monoamine oxidase inhibitors (MAOIs) in Part 2. Just click on the links – Part 1 Part 2

Today we’re going to explore the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and a norepinephrine-dopamine reuptake inhibitor (NDRI).

Selective Serotonin Reuptake Inhibitors (SSRIs)

The first SSRI was fluoxetine (Prozac), introduced in 1988. The SSRIs are – citalopram (Celexa), dapoxetine (Priligy), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), and vilazodone (Viibyrd) (approved by the FDA just last month).

How Do SSRIs Work?

Serotonin is a neurotransmitter believed to be involved in the generation of mood and anxiety issues. In Part 1 we discussed the dynamics of reuptake. The SSRIs inhibit the reuptake of serotonin, allowing more to stick around as neurons communicate.

Why Would I Take an SSRI?

The SSRIs are prescribed for the treatment of depression, anxiety disorders, eating disorders, chronic pain, irritable bowel syndrome, premature ejaculation, and more.

Any Side Effects?

SSRI side effects include dry mouth, constipation, nausea, fatigue, urinary retention, appetite/weight changes, tremor, difficulty achieving orgasm, erectile dysfunction, and decreased libido.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

The first SNRI, venlafaxine (Effexor), was introduced in 1994. The SNRIs are – venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), milnacipran (Dalcipran), and sibutramine (Meridia).

How Do SNRIs Work?

Refer to the “How Do’s” of the SSRIs, and add the neurotransmitter norepinephrine.

Why Would I Take an SNRI?

First and foremost, SNRIs are prescribed for depression. They’re also used for the treatment of the anxiety disorders, neuropathic pain, fibromyalgia syndrome, and the relief of menopausal symptoms.

Any Side Effects?

Refer to the side effects for the SSRIs. However, some reports suggest SNRI side effects may not be as severe. And with regard to sexual side effects, though the SNRIs have the same symptoms as the SSRIs, an increase in libido has been reported.

Any Other Concerns?

High blood pressure needs to be managed and monitored. Duloxetine (Cymbalta) has been associated with liver failure, so it’s not an option for chronic alcohol users or those with liver disease.

Norepinephrine-Dopamine Reuptake Inhibitor (NDRI)

Bupropion (Wellbutrin, Zyban, Budeprion) made the scene in 1974. On its own it’s an effective antidepressant. But it’s frequently used as an add-on when the SSRIs aren’t working as expected. It’s also used as a smoking cessation aid. Of note, bupropion does not cause weight gain or sexual dysfunction.

How Does bupropion (Wellbutrin, Zyban) Work?

Bupropion is known as an atypical antidepressant. What makes it unique is its dance with the neurotransmitter dopamine. It’s twice that of its action with norepinephrine. It’s success as a smoking cessation aid is due to its effect on acetylcholine (a neurotransmitter) receptors.

Why Would I Take It?

Bupropion is used to treat depression, the symptoms of smoking cessation, social phobia (aka social anxiety), anxiety co-existing with depression, sexual dysfunction, obesity, adult ADHD, and neuropathic pain. It may also be useful in the treatment of Crohn’s Disease and psoriasis.

The fact that bupropion doesn’t cause weight gain or sexual dysfunction makes it the preferred choice for many.

Any Side Effects?

Common side effects include agitation, anxiety, buzzing in the ears, skin rash, hives, itching, and headache.

Bupropion lowers seizure threshold, but at recommended doses it shouldn’t present problems. Hypertension, resulting in headaches, blurred vision, and other symptoms could be an issue. Blood pressure monitoring may be suggested.

 Any Other Concerns?

Bupropion may cause anaphylaxis, which can be life-threatening. So if you’re experiencing itching, a rash, swelling of the face, tongue, and throat; breathing difficulty, or chest pain – seek immediate medical attention.

The following apply to all of the medicines discussed in the series…

In 2007, the FDA ordered expanded black-box warnings regarding an increased risk of suicidal symptoms in users younger than 24. There’s quite a bit of controversy here; nonetheless, I need to provide the heads-up.

Alcohol, drug, and supplement interaction is always a concern. Chat with your physician regarding the meds or supplements you’re taking – or considering.

The sudden cessation of any antidepressant is a bad idea. You won’t like the outcome! Here’s a link to the first piece of a series I did on antidepressant discontinuation syndrome.

Well, that’ll do it for today’s discussion. Be sure to come back tomorrow for the final piece in the series – a summary, which will include my personal thoughts on antidepressants.

You may find the FDAs Information for Consumers website helpful. Click here and you’re there.

Be sure to join the chipur crowd on my free weekly newsletter mailing list. And I’ll send along a gift! Click right here.

  • I received an email from a chipur reader the other day. Our exchange will be helpful to many, so with the reader’s permission here goes…

    hello,i am glad i have found your site,but i am allergic to antidepressants.i break out in hives and rashes,and the last one i tried prozac put me in the hospital my throat swelled up and i could not breath.not to mention i wanted to kill myself.i am not clinically depressed,i suffer from chronic back pain.i have not found much online as to why.but what i did read is antidepressants dont really work.what are your thoughts.thankyou

    My reply…
    I don’t think the antidepressant itself is causing the allergic reaction(s). In my opinion, your misery can be attributed to ingredients used in the capsule, filler, coating, etc. For example, dyes can cause huge problems for many. Don’t know if you’ve been using the generic or brand preparation. If generic, many times there are several manufacturers of the same med. Check-out the manufacturer of what you’ve been using and see if you can switch to a different one.
     

  • I know it’s frustrating, Lisa. What about using a liquid? I’m pretty sure Celexa, Cymbalta, Prozac, Paxil, and Lexapro come in a liquid. Perhaps others? And there’s the MAOI patch selegiline (Emsam). Just pumping ideas…

  • Qnbella110

    I just started taking viibryd and I noticed I’m very tired. I’m worried about weight gain too should I be

    • Hi There!

      Thanks for visiting chipur and participating. I know it’s scary starting a new psychotropic medication, but side effects such as weight gain aren’t guarantees. So don’t sell yourself on misery that may not present.

      I encourage you to check out the chipur forum – all sorts of threads and posts on Viibryd. Here’s the link http://chipur.com/forum/meds-supplements-devices/

      chipur is here for you!

      Bill

  • panhandlep1@juno.com

    are viibrid and celexa in the same catagory of mecicines?

    • Close. Celexa is a selective serotonin reuptake inhibitor (SSRI). Viibryd is an SSRI and a 5-HT1A receptor partial agonist. Thanks for your participation…
      Bill

  • Jodi

    Hi, I know this is an old post, but still relevant. I have a question. I’ve been on sertraline for a few months. This is the first time I’ve been on an antidepressant. It worked well at first, but the effects are starting to lessen. Additionally, I have had crazy weight gain. So I’m looking to switch drugs. My therapist has suggested Celexa, and a friend who has been on just about all of them has suggested Wellbutrin. I know they are different types, and Celexa is in the same category as Sertraline, but beyond that I’m not really sure what the difference is or what I should switch to. I have an appointment with my GP in a few weeks and I’d like to have some idea of what I’m looking at before I go in.

    • Hi Jodi!

      Glad you stopped-by and contributed. Let’s see how we can help.

      First of all, and not that it makes a huge difference, I’m wondering if you’re taking an antidepressant for depression or anxiety – maybe both? More of a factor for prescribing physician – I’m just curious.

      You have it right, sertraline (Zoloft) and citalopram (Celexa) are SSRIs. Bupropion (Wellbutrin) is an NDRI (norepinephrine dopamine reuptake inhibitor). You’ve been taking sertraline for a few months; however, I don’t know the dosage you’ve worked up to. In terms of efficacy and weight gain, I can’t imagine you’d be significantly better-off with citalopram – that would include any sexual side effects you may be experiencing. Actually, same likely applies to bupropion, except it’s believed to have few sexual side effects. Welcome to the world of psychotropics! Sorry to say, it’s all a crap-shoot. One thing works for one person and doesn’t at all help for the next. Now, you mentioned you’re working with your GP. I’m assuming you have a good relationship with her/him. May be worth looking into a psychiatrist.

      Bottom-line – I can’t make a worthy recommendation. Wouldn’t be fair to you. I’d only suggest you determine whether or not your sertraline dosage is truly therapeutic. Then consider a change.

      Thank you for your visit, Jodi, and I appreciate your comment…

      Bill

      • One other thought – several hours later. I said the world of psychotropics is a crap-shoot. I’ll stand by that; however, things may be changing. I posted this piece on a tool for understanding genetic and biological markers that best inform responses to psychiatric treatments some time ago. Darned interesting, and available now. FYI! Bill
        http://chipur.com/depressed-which-antidepressant-is-right-for-you-enter-genetics/

      • Jodi

        Thanks for the response. To answer your queries, I’m taking it for depression, and I’m on 50 mg. We haven’t raised it at all. I was initially thinking about asking to raise it, but I’m afraid of even worse weight gain. I’ve had to buy new clothes and I think that somewhat contributes to the decreasing effect.

        As for my GP, she actually has a background in Psychology also, so I feel completely comfortable with her in this.

        As a side note, I haven’t had any sexual side effects with sertraline, though that side effect is of no concern to me either way. I just can’t deal with any more weight gain. I work out and eat better and still gain. It’s frustrating. lol

      • Yeah, Jodi, no doubt frustrating. Totally understand hesitance to increase. Keep working with your doc on options. An augmenting option would be Deplin. Expensive; however, some if my clients report good results. Posted a piece on it some time ago. Type it in the search box and off you go.

        Bill

  • sara

    i started on 30mg duloxetine on 11th nov 2014 now 30th nov have chronic itching, sore skin, sores where i am scratching itching only started 2 days ago will it stop going to doctor tomorrow monday 1st dec 2014 any advice please dulox has helped me with pain and major depression but cant stand the skin thing please help from sara in australia

    • Hi, Sara! So sorry you’re having such a rough go of things. Heck, if you’re in Australia, you may have already seen your doc by the time your read this.

      “Will it stop?” Man, I wish I could say it would for sure. Thing is, it just might – being a side effect that falls by the wayside in time. However, as you’ve likely learned, taking psychotropic medicines is a crap-shoot when it comes to results, side effects, and more. I’m glad you’re seeing your doc Monday. Would you mind posting the outcome?

      Appreciate your visit and participation, Sara. Do hang in there…

      Bill

  • Joeh

    Thank you so much @chipur:disqus for taking your time for explaining this to us. You’ve convinced me to take meds. I’ve done my research. I will talk about this next tuesday with my counselor.

    I read in another great website that “Depression has 2 major pathways in the brain, the emotional pathway which causes sadness, crying guilt, suicidal thoughts, anxiety, worry and the ‘cognitive’ pathway which causes lack of attention, concentration, energy, motivation, pleasure, sex drive.

    If you have ’emotional’ symptoms choose ssri or snri, if you have ‘cognitive symptoms chose dnri, many times these overlap and meds also overlap”

    It will be either SNRI or NDRI. I’m thinking NDRI would work best for me (and all the Cognitive side). What are your thoughts? Will be greatly appreciated.

  • Monica

    Hello. Very excited to have found your website. Having trouble finding an answer to my question and I’m hoping you may be able to help me.
    I am currently taking fetzima for depression. I have been on it for close to seven months and it seems to have helped a good bit. However, the major downfall is that my libido has dropped down to almost nothing. That in itself is depressing as it doesn’t help a marriage much. But I must add that my husband has been positively wonderful and 1000% understanding. I myself am just not real happy about it. So after discussing it with my doctor, I was given a script for Wellbutrin because it doesn’t have the seritonine in it.
    My question to you is what is the best coarse of action to take in switching from one to the other. The thought of switching is terrifying to me, so I want to make sure I do it safely.
    Thank you very much for your time and help.

    • Hang in there, Monica. Finishing with a couple of clients. Will provide a nice reply here in a bit. Thank you for your visit and comment…

      Bill

      • Monica

        No problem. I appreciate your response and your time.

      • Okay, Monica, let’s see what we have here. Oh, thank you again for your visit and contribution. Not only does it mean a lot to me, but it’ll mean a lot to those who stop-by in the days ahead.

        So now to your situation. Makes sense to transition from levomilnacipran (Fetzima) to bupropion (Wellbutrin), given what’s going-on. Incidentally, glad you and your husband have worked closely together in managing the issue. Sounds like a healthy marriage.

        Well, now I have to offer my universal disclaimer. In answering your question, please understand I’m a humble counselor, not a psychiatrist. Okay? Now, with all that build-up, I’m not going to offer a taper schedule for the Fetzima (or a start-up schedule for the Wellbutrin). That needs to come from your doc, and if s/he didn’t offer, I’d sure ask. That said, I can find no major interaction concerns re an SNRI and Wellbutrin (NDRI). So if there’s overlap, I wouldn’t freak about it. In fact, I just spoke with a psychiatrist friend who shrugged his shoulders in “no big deal” when I inquired about the transition. Still, I’m not a psychiatrist, and I want you to further discuss the matter with your doc. Got it?

        Hey! Best to you during the transition, and don’t overly fret, Monica (though that’s just how we roll at times). And you and your hubbie enjoy that restored libido…

        Bill

      • Monica

        Thank you so very much for your feed back. I couldn’t help but laugh when I read where you wrote “do not overly fret”. It’s funny to me because besides my father, I’m the only person I know who seems to live with virtually no stress. For example….. Sometimes “things” just happen in your life that are completely out of your control. Where many people would normally worry about that “thing”, I try my best to live by the fact that once “things” happen, the key word to me is HAPPENED. Since it was out of my control in the first place and there’s nothing I can do to go back and change it, i feel that it would be unhealthy for me to waste my energy on worrying or stressing over it. At the same time however, if there’s something that can be done to make the remaining situation better, then that’s what I want to do. That’s where I choose to look at the bright side of the “thing” that happened. Also, when it comes to other people’s problems, I choose not to take on the stress and worry for the ones who DO NOT care to better their situation. Am I making sense or do I sound emotionally cruel?

        Anyway, the main reason I mention about myself being a stress free person is because it was the one thing that made it so hard for me to understand how I could have become depressed in the first place….which then made it twice as hard for me to figure out how to come out and admit it. With time and help, I’ve come to learn and accept that it’s more about the imbalance in my brain than anything else. That bit of info made it so much easier for me to answer the questions……. “what happened?”…….”if nothing happened, then what’s wrong?”, which came from my family and friends.

        Okay, back to my reason for writing you….. I’ve finished my transition from the Fetzima to the Wellbutrin. Per my pharmacist instructions for weaning off the Fetzima, I basically did three cycles of ‘one day on – two days off’. Following the end of that third cycle, I started the Wellbutrin. I’m not sure if successful is the right word to describe the whole transition process because towards the end of it I started to feel AND SEE a not-so-good change in myself. I was truly surprised by it too. I guess I just didn’t think anything would change in such a short period of time. I was to the point where I was starting to feel those familiar feelings of not wanting to get off the sofa or even out of my bed.

        But as of today, day 11 on the Wellbutrin, I am very happy to report that those negative feelings have gone away and I’m feeling quite well. In all honesty though, I feel no different than the way I felt when I was taking the Fetzima, which is not what I was striving for. But in all fairness to Wellbutrin and its affects, I’m fully aware that it will still be several weeks, give or take, before it is fully in my system. So until then, any comparisons I see between the two meds, I will only consider them as ‘work in progress’ towards achieving the change I’m hoping for. (I hope I worded that in a way that makes sense, lol!)

        In closing, I must first apologize for rambling on so much. Never did I intend to write so much, lol! Second, and most importantly, I want to thank you again for helping me with my situation. I greatly appreciate the fact that you took your personal time out to read my letter of concerns and then to respond back to me….and very quickly if I might add! Take care, and keep up the great work and great service you provide to all of us!!!!

        Sincerely,
        Monica

        PS. Thanks for the kind words regarding my hubby. He is without a doubt, “one in a million”!!!

      • Ah, Monica – glad everything’s coming along. And glad you’re patient (and not fretting LOL) re the Wellbutrin handling its intended mission. Smart, I’d say.

        “…when it comes to other people’s problems, I choose not to take on the stress and worry for the ones who DO NOT care to better their situation. Am I making sense or do I sound emotionally cruel?”

        Sure, it makes sense – and, no, you don’t sound emotionally cruel. Fact is, when it comes to helping, there are limits. And when we find ourselves working harder than the one in need, we have to start asking some questions. Now, in my line of work, it’s up to me to assist in uncovering why someone doesn’t care to better their situation (motivational interviewing) http://chipur.com/the-ambivalence-mire-get-out-of-the-mud-with-motivational-interviewing/. However, for one who isn’t a professional, I get it. Actually, you sound like a wonderful human being.

        You can’t know how much I appreciate the detail with which you’ve written. I mean, to have your contribution here for the next person who comes-by looking for help is so valuable.

        You take care, as well, Monica. And stop-by again…
        Bill

      • Monica

        Thanks for the positive feedback. It’s reaffirming for me to know that in some situations it is best for me to take care of myself befor taking care of others. After 25 years of seeing the same counselor, the one thing I’ve learned, if nothing else, is that taking care of myself is most important because if not, I would not be any good for anyone else. In fact, I know that I am who I am because of my counselor. She is the best and she has taught me so many wonderful things to get me through my daily life. If more people would consider counseling instead scarfing at it, most would be better off in their lives. Mentally and emotionally. For those who say “I don’t have any problems”, you need to know that you don’t need to have a problem to see a counselor. A counselor is not a psychiatrist…they are in two different fields of work. Similar in some sense, but different in others. I promise you, when you think you having nothing to talk about of nothing wrong, you’ll be quite surprised once you start talking to a counselor. You can always look at it as weekly or monthly “tune-up’s” for yourself.

        Thanks again Chipur. I’m glad to know that expressing myself could possibly help others. Helping others is something I always loved to do. Beginning my high school life was when my friends turned to me the most because they said I was NEVER judgemental towards them. I’ve always told them that I wasn’t in their shoes, so how could I be judgemental. Everything that everyone does is part of being a human being. 😄

      • Please keep coming back and participating, Monica. Your input is valuable…
        Bill

  • Tiffany Buczek

    I was taking Effexor for about 12 years (after unsuccessful attempts with Prozac and Zoloft). It stopped working for me. I was getting very frequent depressive episodes, no motivation, sleeping for 11 hours a day. I tried generic Wellbutrin, while subsequently trying to wean myself off the Effexor. It’s been pure hell. I’ve decreased the Effexor very slowly, but I finally had to take 37.5 mg of Effexor after 4 days without any, due to severe dizziness, headaches, rages, crying spells, lethargy, etc. Everything I read about Wellbutrin says to give it time, but I’m not used to feeling worse, before feeling better. It’s to the point where I can’t function anymore. Not sure whether to go off Wellbutrin and try Prestiq. Or stick it out with the Wellbutrin. Or add Prestiq to Wellbutrin. I have both cognitive and emotional problems, but the Effexor alone did work for many years. I’m so confused.

    • Hi, Tiffany…

      Welcome! Really appreciate your visit and sharing. Please keep in mind how important it is for others who’ll stop-by and read your comment – with hopefully a decent reply from yours truly. None of it happens without your contribution.

      Sorry you’re having such a rough go. As you said, “It’s been pure hell.” And isn’t that just the way it goes with the crap-shoot called psychotropic meds? Today’s antidepressants can be so confusing and frustrating. And that’s why I’m fired-up by researchers looking long and hard at the neurotransmitter glutamate, as opposed to sticking with the monoamines: serotonin, norepinephrine, dopamine. Here’s an article I wrote some time ago on GLYX-13, which is in development. It’ll explain the glutamate angle http://chipur.com/i-feel-depressed-so-whats-in-the-relief-pipeline-lets-chat-glyx-13/

      So now to your dilemma. And please remember I’m a counselor, not a medical doctor. And, by the way, I’m hoping you’re working with a psychiatrist. More so hoping s/he is a true traveling partner along your journey.

      You mentioned generic Wellbutrin, so I’m going to use bupropion (say that five times real fast) here. I’m sure you know bupropion influences norepinephrine and dopamine, whereas Effexor hits norepinephrine and serotonin. So you’re dealing with a different action. But then again, the Effexor no longer worked, so a “different action” was indicated. Regarding bupropion, it seems physical symptoms such as energy, sleep, and appetite ought to show some improvement in one to two weeks. In fact, my sources have told me if that happens, it’s a positive sign re bupropion being a keeper for the long haul. When it comes to depression, anhedonia, and amotivation improvement, I’m thinking four to six weeks ought to do it. So if you’re still within that, say, two week window of starting bupropion, I don’t know that I’d surrender just yet. As for Pristiq? Darned near everything I’ve read says it’s no more efficacious than Effexor. And why would it be? It’s just the active metabolite of Effexor (and a great patent replacement for Effexor).

      One last observation. And please take this within the context of throwing ideas out there, okay? When I hear someone say their antidepressant stopped working (“Prozac poop-out”), something called “soft bipolarity” comes to mind. Just something to swirl-around, Tiffany. I did a two part series on it five years ago. Here are the links http://chipur.com/soft-bipolar-disorder-its-possible/ http://chipur.com/soft-bipolar-disorder-the-meds-factor/

      So there you have it, Tiffany. Shootin’ from the hip, and hoping it’s of some help. Please keep us updated. And thanks again for visiting – and sharing…

      Bill

      • Tiffany Buczek

        Thanks so much for your reply! I, in fact, met with my psych last night and he wants me to wait it out another month, while trying to stop the Effexor again cold turkey. He doesn’t seem to think my symptoms are from Effexor withdrawal, but rather from Wellbutrin side effects. I’m not sure I agree, but whatever. I tried Wellbutrin about 5 years ago and abruptly stopped the Effexor and never had any problems with the transition so why it’s so difficult now, I have no idea.

        I wish there was a test to determine which neurotransmitter one is low in. Wouldn’t that make choosing a medicine so much easier? Oh well. Even though I’ve been on Wellbutrin about 2 months, I’ve only just worked myself up to the standard dose of 150 mg a week ago. The fact that I haven’t had one day where I can honestly say I feel good is disconcerting. Too bad it’s such a long wait and see process.

      • “I wish there was a test to determine which neurotransmitter one is low in. Wouldn’t that make choosing a medicine so much easier?”

        Wellllllll, it’s young science; however, it’s better than nothing. How ’bout a test/tool for understanding genetic and biological markers that best inform responses to psychotropic meds? It exists, and I’ve had clients use it. Check it out, Tiffany http://chipur.com/depressed-which-antidepressant-is-right-for-you-enter-genetics/

        Again, so sorry you’re struggling. Feel free to stop-by anytime and vent, okay?

        Bill